One Time Credit-Card Payment Authorization Form

This form has been modified since it was saved. Please review all fields before submitting.

Sign and complete this form to authorize Kneehill County to make a one-time debit to your credit card listed below.

By signing this form, you give us permission to debit your credit card for the amount indicated. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

For your credit card security, please call in your credit card number at 403-443-5541. For your protection, we do not receive credit card numbers and CSV's by email or fax.

Transaction Date*

Transaction Date

Purpose of Charge

(i.e Planning, County Map, A/R Account...etc.)

Charge Amount*

Payment Method*

Visa

Mastercard

Name of Cardholder*

Phone Number*

Address1*

Address2

City*

Province

Postal Code

Kneehill County shall not be responsible for the security of any information during delivery by mail or email, and the cardholder agrees as a condition of paying on credit card that it hereby releases and holds harmless Kneehill County from any and all claims arising therefrom.

Check this box if you agree to have Kneehill County charge your credit card in the amount shown above.*

I agree

The personal information on this form is being collected under the authority of section 33 (c) of the Freedom of Information and Protection of Privacy Act (FOIP) and will be used for the administration of Kneehill County Programs and Services. Should you have any questions regarding the collection, use, and retention of your personal information, contact Kneehill County by email: office@kneehillcounty.com, or phone 403-443-5541.